Thursday, January 31, 2013

The
NHS has been subjected to reform, re-reform and re-re-reform over a number of
years with little actual improvement in clinical care to patients. Yet the
bonus culture has led to side effects that were normally the domain of bankers
and financiers.

But
when you have such Pavlovian salivating dog being in charge of Hospitals and
Health Care, the outcome would have been predictable.

As
we have seen, banks failed and yet there is money to rescue them, our money. When
NHS Hospitals fail, it is a sure way to persuade the general public to accept
private providers.

But
why are we able to promote NHS as a quality brand in places like Dubai?

“As the film ends an abandoned baby could be heard crying as the rain stopped. The priest who was probably going to kill himself for how bad the world has become regained his faith in humanity when the woodcutter offered to look after the baby.He had 6 children and he was struggling; but he decided to keep the abandoned baby as one more would not have made his life any more difficult.”Are we going to have a similar ending: one of hope, hope for humanity.

An
unprecedented array of key figures in theNHSwill be castigated next week in the
hard-hitting final report of a public inquiry into who caused – or failed to
prevent – the Mid Staffordshire healthcare scandal. Between 400 and 1,200
people died unnecessarily as a result of treatment at Stafford
hospital between January 2005 and March 2009.

The report by Robert Francis QC, who chaired an inquiry lasting
more than two years, should help grieving relatives understand why poor care
went unchecked for so long. But it will be devastating for the NHS, and a large
number of managers, health professionals and regulators will be criticised for
their role in the worst hospital scandal in recent memory.

They will be accused of incompetence, misjudgment and not
responding properly to evidence that patients' safety was at risk from neglect,
too few staff and sometimes inhuman care.

Francis's report was delayed in October after he sent warning
letters to 20 individuals or organisations. According to sources close to the
inquiry, the letters set out privately and in advance the criticisms he
intended to make publicly in his final report and the evidence on which he had
based his conclusions.

Many recipients, who were among the 164 witnesses who gave
evidence during 139 days of hearings over 37 weeks between November 2010 and
December 2011, sought legal advice before replying.

"Nobody in the NHS will emerge from Francis with any
credit, I think – from the most senior NHS leaders to everyone at the hospital
itself," said Katherine Murphy, chief executive of the Patients Association,
who had core participant status at the inquiry.

"I hope the report is wide-ranging, in-depth and unsparing
in explaining why these things happened and why NHS regulation failed so
abysmally and why senior NHS figures behaved as they did."

Mr Yeates, who resigned with a pay-off of more than £400,000 and a £1
million pension pot from Mid Staffordshire Foundation Trust, which runs the
hospital, told the inquiry he was too ill to appear in person.

A decision is expected later on plans to close the Accident and Emergency department at Lewisham Hospital in south-east London and downgrade its maternity unit.

The proposal came after neighbouring South London Healthcare NHS Trust (SLHT) ran up debts of £150m.

What hope is there for the NHS when a hospital without the problems of Mid Staffordshire face downgrading? Would it not be better for bankruptcy and a true default of the PFI? Or should we bankrupt the government?

Historically, London Medical Schools were established in the hospitals in the poorer areas in order that medical students could have enough cases to practice on and in return the poor patients had the advantages of free treatment.

There is nothing like volume for medical training.

For a very long time, doctors trained in London were one of the most valued. A Senior Registrar (yes, in those days) can easily get a Consultant job anywhere else in the Commonwealth and often a Professorship (British styled ones). In other words London trained doctors are a highly exportable commodity.

“The shape of the London hospital system has also been affected by developments in medical science and medical education. In many ways it has been the activities of doctors which have determined the pattern of the hospitals. The increasing ability to treat disease and improved standards of care shortened the time patients spent in hospital, raised the demand for services and led to an escalation of cost. The development of specialisation led first to the development of the special hospitals and later to special departments within the general hospitals. Advances in bacteriology, biochemistry, physiology and radiology cre­ated the need for laboratory accommodation and service departments, so that hospitals no longer consisted merely of an operating theatre and a series of wards. Sub-specialisation ultimately meant that services had to be organised on a regional basis and the very reputation of the capital’s doctors affected the number of patients to be seen. The hospitals of central London have long served a population much larger than their local residents.

It is against this complex background of population movement, poor social conditions, disease, wealth and poverty, professional expertise, critical comment and publicity that the London hospitals developed. A complex institutional pattern emerged. Voluntary hospitals grew up beside the ancient royal and endowed hospitals. A local government service providing institutional care for sick paupers developed alongside the hospitals. A network of fever hospitals, scientifically planned from the outset, was established. Physically near to each other, staffed by doctors who had trained in the same hospitals, and often serving the same people, the different objectives and status of the institutions led them to work in virtual isolation from each other. Each hospital had its own traditions and nobody standing in the middle of a ward could have doubted for a moment the type of hospital he was in. Countless details gave each an atmosphere of its own, and the different methods of administration and levels of staffing set them apart.” Geoffrey Rivett

Keith Palmer recently produced a detailed report that involved at least three such historic hospitals:

…………competition and choice in contestable services may inadvertently cause deterioration in the quality of essential services provided by financially challenged trusts.

Market forces alone will rarely drive trusts into voluntary agreement to reconfigure services in ways that will improve the quality of patient care as well as drive down costs. In many cases the most likely outcome will be continued deterioration in both the quality of care and the financial position. The NHS will have no alternative but to continue to fund their deficits or allow them to fail.

The NHS is entering a period of unprecedented financial challenges that will result in major changes to the provision of health services. While all areas of health care will be affected, acute hospitals face particular challenges because of the high proportion of the NHS budget spent in hospitals. Add in the need to reconfigure specialist services in many parts of the country to deliver improvements in outcomes and the requirement that all NHS trusts should become foundation trusts by 2014, and a period of fundamental service and organisational change is in prospect.

Keith Palmer’s analysis of the reconfiguration of acute hospital services in south-east London offers a timely and sobering contribution to the emerging debate on how service and organisational change should be taken forward across the NHS in England. His painstaking account of the trials and tribulations of bringing together four acute hospital trusts with a history of financial problems, the challenge of funding large and long-term private finance initiative (PFI) commitments and difficulties in sustaining high-quality specialist care in hospitals in close proximity to each other offers important learning for the future.

Three major implications for policy-makers stand out.

First, Palmer argues that market forces are unlikely to deliver desirable service reconfiguration, and only ‘strong commissioning’ stands a chance of bringing about the changes needed to improve quality and drive down costs. As he shows, in the case of south-east London, primary care trusts (PCTs) were either unwilling or unable to intervene to tackle the challenges facing acute hospitals, and only when the strategic health authority (SHA) became involved was some progress made. General practice commissioners face formidable obstacles in being more effective than PCTs in leading complex service reconfigurations, raising questions as to where responsibility for taking forward this work will rest when SHAs are abolished.

Second, Palmer questions the strategy of merging acute hospitals providing broadly similar services. His preferred alternative is to support acquisitions of financially challenged NHS trusts by high-performing foundation trusts on the grounds that this will facilitate improvements in quality and outcomes through the accelerated adoption of best practice models of care. Although provider consolidation along these lines might reduce competition in the health care market, the consequences have to be weighed against the risk that quality will deteriorate ifMonitor in its role as the economic regulator rules against such acquisitions. The implication is that organisational changes need to be based on a thorough assessment of how to bring about improvements in quality, particularly through organisations that perform well lending support to those that are challenged.

Third, Palmer contends that the government will need to find a way of dealing with legacy debt and the costs of PFI commitments to support the acquisition of financially challenged trusts. Neither high-performing foundation trusts nor private sector providers are likely to be willing to take on challenged trusts without such support, and competition law requires that all parties should be treated equally if a market in acquisitions opens up. At a time of public spending constraint it will not be easy to identify additional resources but failure to do so may simply increase the financial and service challenges facing the NHS and store up even greater problems in future. The lessons from this paper need to be acted on in a context in which ministers have emphasised that service reconfigurations should be based on support from general practice commissioners and public and patient involvement. They have also argued that service changes should be consistent with clinical evidence and help to facilitate patient choice. The government’s decision to bring a halt to the work being undertaken by Healthcare for London to concentrate some specialist services to improve outcomes underlines the challenges in acting on the evidence presented in this paper.

In reality, the requirement to find up to £20 billion of efficiency savings by 2015 and to establish all NHS trusts as foundation trusts by 2014 will necessitate a stronger approach to commissioning than currently envisaged to ensure that quality is improved at the same time as costs are brought under control. The expertise of general practice commissioners needs to be married with the ability to lead complex service reconfigurations across large populations if the lessons from south-east London are to have lasting impact.

UK health secretary Andrew Lansley was once prime minister David Cameron’s boss—a little remarked fact that may partly account for the fearlessness with which Mr Lansley felt able to spring upon cabinet colleagues his controversial plans for the NHS. When he was head of the Conservative research department in the early 1990s, Mr Lansley gave Mr Cameron and George Osborne, now chancellor, their first jobs in politics.

“That explains why he and David Cameron have a good relationship and why Andrew is trusted on health,” says Andrew Jones, formerly a Conservative policy adviser and now group medical director of Nuffield Health.

It is a common practice for politicians to ignore professional advice. Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.

Thursday, January 17, 2013

.....“Fortunately
a group from Tasmania[1], of all places, decided to carry out a control study, by suggesting
to prospective parents randomly how to place their babies, on their tummies or
on their back. It is amazing how
under-reactive some parents really are and do not mind subjecting their
precious babies to a life and death situation. Now it is considered unethical to
conduct a control study in such a way.
If a drug is so obviously life-saving another way of assessing its value
has to be found, rather than denying half the patients the chance of survival.”

From: The Cockroach Catcher

[1]Prospective cohort study of prone sleeping position and sudden infant
death syndrome. Dwyer. (Lancet
1991; 337: 1244-1247). Lancet. 1985 Dec 14;2(8468):1346–1349. The "IslandState"
provided a perfect source population for unbiased selection of cases and
comparison samples or controls. Further, the land area and population size
(around 500 000 people) made follow-up of cohorts relatively easy. Thus, Tasmania had important
advantages for the two major strategies used to search for environmental and
lifestyle causes of disease — case-control and cohort studies. Terence
Dwyer, MD, FAFPHM, Director.

Summary. A population-based retrospective case-control study has been conducted in Tasmania since October 1988. Study measurements pertained to the scene of death of last sleep, as well as a verbal questionnaire on relevant exposures. From 1 October 1988 to 1 October 1991, 62 cases of sudden infant death syndrome (SIDS) occurred. Case response rate for retrospective interviews was 94% (58/62). The initial control response rate was 84% (101/121). After stratification for maternal age and birthweight, there was no increase in risk associated with the usual side position (odds ratio [OR] 1.05 [0.27, 5.02]), compared with the supine position (OR 1.00, reference). The prone position was associated with increased risk [OR 5.70 (1.67,25.58)], relative to the supine position. In the final multivariable model, predictors of SIDS in this study were usual prone position (P < 0.001), maternal smoking (P = 0.008), a family history of asthma (P = 0.045) and bedroom heating during last sleep (P = 0.039). Protective factors were maternal age over 25 years (P = 0.013) and more than one child health clinic attendance (P = 0.003). The results provide further support for current health education activities which aim to inform parents of modifiable risk factors for SIDS, including the prone sleeping position, thermal stress and infant exposure to tobacco smoke.

Thank you for your visit.

Subscribe To The Cockroach Catcher

A budding child psychiatrist

About Me

Before my retirement, I practised child psychiatry for 30 years, 25 of which as a consultant and director. After these years of clinical practice, I felt compelled to tell my stories as I have my doubts as to the validity of some of the assertions of the medical world.
I am the author of the book The Cockroach Catcher, which is based on my work as an NHS child psychiatrist. Contact me on: cockroachcatcher at gmail dot com

Eric Kandel, M.D., who was awarded the Nobel Prize in 2000 for discovering molecular mechanisms of memory storage, told the crowd at last ...

Followers

The contents of Cockroach Catcher Blog (text and photos) are strictly the copyright of Dr Am Ang Zhang and all rights are reserved. Other bloggers are welcome to quote and use any of the content of the articles on the internet or in their own blogs as long as it is acknowledged.

Anyone wishing to use substantial parts or all of any of the articles is asked to contact Dr Am Ang Zhang (cockroachcatcher (at)gmail (dot)com) in advance.